CaRMS Tour 2016

It's CaRMS tour time! There were tons of very well-dressed graduating medical students running around the hospital last week, getting tours, doing interviews, and meeting their potential future co-residents. A lot of them also looked terrified. Really terrified.

It was kind of interesting being a clerk on rotation during this time. I'm old enough (and look old enough) that many people don't immediately assume I'm a student. So when I've been running around this week, a few CaRMS interviewees have been extremely quick to jump out of my way. Not just polite-quick, but "I'm sorry if my presence offends you"-quick. I think some of them think I'm a resident and that they therefore need to be exceptionally nice to me during this time. It's a weird situation, since these people are all ahead of me in training and where I hope to be in a year.

I hope my CaRMS tour next year isn't as stressful at it seems from the outside!

Underpants Gnome Theory of Medical Education

One of the surprises for me in clerkship has been the unique nature of clinical training for physicians relative to that of other healthcare professionals. Before starting medical school, I trained and then briefly worked as one of these other healthcare professionals, receiving accreditation from my overseeing college and all that. My experience during my clinical training time was substantially different from what I've received in medical school.

The basic structure was similar - each week or so, I'd be assigned a preceptor who was working in the hospital, and I'd report to them for my training, pretty much the same as what happens in clerkship now. The difference was in our respective roles and the level of supervision. My preceptor had a job to do aside from training me. However, my job was essentially to do their job. If they had a task to do, I would try to do that task. The two of us basically shared my preceptor's job that they would normally do on their own.

Being inexperienced, I was obviously quite bad at things in the beginning - I was uncertain of what to do at times, horribly slow, and made a LOT of mistakes. Since what I was doing was still the ultimate responsibility of my preceptors, they kept a close eye on me and provided direct assistance when I started to stumble. As I gained more experience, the amount of support I needed declined and my preceptors started to get more comfortable with leaving me more of the job to do. They stopped watching me as closely and slowly gave me more and more independence. By the end, I was basically doing the work on my own, checking in with my preceptors only in exceptional circumstances. When I transitioned to working on my own, the shift in my responsibilities wasn't all that substantial - I was still relatively inexperienced and had a lot to learn to master my full role, but I had already been doing the bulk of the work for months beforehand, under almost the exact same constraints.

Most healthcare professions seem to work this way. A student nurse in clinical training works basically in a nursing role. A pharmacy student essentially acts like a pharmacist. They generally do the same tasks, have the same responsibilities, hold roughly the same hours, and are expected to have the same knowledge base.

Medical education, by contrast, does not follow this framework. There are distinct roles for medical students, residents (with further splits between junior and senior residents), fellows, and fully-licensed physicians. My roles, responsibilities, tasks, hours, and necessary knowledge diverge markedly from the residents, fellows, and physicians who serve as my clinical preceptors. Since my preceptors have different jobs to do than I do, I've found there's far less investment in whether or not I'm doing my job appropriately. They care about the results of whatever task I've been appointed, but more in the way a coworker cares about your performance than in the way a teacher cares about your performance. The ends seem to justify the means in medical education - it rarely matters how I do something in clerkship as long as it all looks alright in the end, and that leaves open a lot of room for mistakes to go unidentified or only caught after-the-fact.

The sharp divide in roles means competence in medical education is backward-looking rather than forward-looking. In my previous program, I had to be declared competent at the job I was going into before I was allowed to work without supervision. In medical education, everyone seems to move to the next step by demonstrating competence at their current role - student, junior resident, senior resident - rather than competence in their future roles, such as being an attending. Knowledge and skills develop at each step with some continuity, but functional knowledge for the future role isn't instilled, resulting in some very difficult and oftentimes unsuccessful transitions between roles.

The underlying premise of medical education is that exposure is a good enough teacher in itself. Yet, this is an Underpants Gnome approach to competency in medical education:

Phase 1: Exposure to clinical experiences.

Phase 2: ???

Phase 3: Competency!

There's quite a bit of evidence to suggest that our current system doesn't prepare learners well enough for the next step of their journey. There's the July Effect in teaching hospitals. Difficult transitions to clerkship, the first year of residency, or full practice are frequently reported.

Canadian residency programs are trying to adopt "Competency-Based Education" models, which appear to include a specific transition to practice component, and similar reforms are rumored to work their way down to the student level, but I'm skeptical about whether that's going to be a change in the fundamental approach at most programs or just a change in semantics. The division of roles between attending physicians, residents, and students is fairly well ingrained in the structure of academic medicine. Without a meshing of roles, it's hard to imagine medicine will move towards the models of other healthcare professions.

Temporary Optimism

I complain a lot about medicine and medical education on this blog. There's a lot about medicine and medical education to complain about. I've got a lot more to get out too, so don't expect that to change any time soon!

However, sometimes things turn out well and we actually do good work. I actually had a pretty good day today. I got to help some people in what I consider to be a meaningful way, where I got to use counselling and half-decent communication as much I suggested new investigations or medications. Plus, while I was running around trying to get everything done in time, I did manage to take enough time with each patient to do a good job, which has not often been the case (more on that later).

So colour me an optimist, if only for the day. Medicine is rife with serious, patient-harming problems, but if you keep an eye open for opportunities, sometimes those problems can be overcome or mitigated. Today had several of those opportunities, so it was a good day.

Likes and Dislikes in Oncology

I took a selective in Oncology, which comprised both Medical and Radiation Oncology. Cancer is common and terrifying, so it was good to dig into the disease a bit further. Continuing on my series of rotation take-aways, here are my thoughts on my rotation:

1) Conversations
Oncology isn't that heavy on the medicine side of things - the science behind treatments is complex and incredibly interesting, but the actual approach to treatment is fairly formulaic. Where there is a degree of complex decision-making is in considering a patient's preferences, as well as providing education and counselling. As someone who takes the most enjoyment from medicine when actually talking to patients and helping them work through their condition, I loved this aspect of the field.

2) Time
Oncologists have time. Time to talk with their patients. Time to consider their medical and social situations. Time to arrange long-term supports. Cancer is scary, so we treat cancer patients pretty well from what I've seen. Plenty of room for improvement still exists, but it is kind of amazing to see patients being given plenty of attention and resources, in stark contrast to the way some other maladies are treated.

3) Death
For understandable reasons, death is a pretty big topic in Oncology. Many patients die, and die quickly. Moreover, patients are aware of their impending mortality. It's an element that scares a lot of people away from the field, because, well, death is scary. I find I don't mind discussing death though. It's inevitable, and physicians can do a lot to manage life on the way to death. I'm of the view that physicians are not meant to stop death at all costs, but rather to facilitate the best life possible - that second goal is very achievable in terminal patients, and I derive a lot of satisfaction from that.

4) Double-Edged Sword
For patients not yet clearly on the palliative track, the challenge with cancer treatments is that they all have trade-offs. Surgery, radiation, and chemo can all have side-effects, some quite significant. We're getting better treatments that minimize the more debilitating risks, but each approach still involves a good measure of chance. More than death, this is the element of working in Oncology that gives me pause. No matter how well an Oncologist practices, they will cause their patients harm as a course of their treatments. Much of this is temporary and can be managed. Some of it is permanent and without recourse. Good communication of risks and benefits before starting treatment can at least prepare patients for these possibilities, but it's still quite a burden to accept that someone was injured because of the treatment plan you, as a physician, put in place.

5) The Happiness Test

With few exceptions, Oncology physicians seemed to be very happy people. They work with the most life-breaking diseases in the world, so I suppose it takes an optimistic person to stay in that field. Everyone was super nice, not just to the patients but to me as well. You definitely notice a difference when there are smiles on most people's faces, even as they're hard at work.

Communication

Errors in medicine are common. Really common. Like, shockingly, awfully common.

Luckily many of these errors result in no or minimal harm to patients, either because they're caught in time or because they're relatively minor mistakes. Yet, small errors could just as easily be big errors and small errors have a tendency to snowball, where a series of small errors results in big harm.

Most commonly, medical errors are due to poor communication. That is, everyone is acting as they think is appropriate, but they're missing information that would change their actions, information other persons have.

I'm on my CTU rotation now and it's striking to see how often communication errors occur in inpatient medicine. It's not just every day, it's every hour of every day, involving every patient who steps through the hospital doors.

Yet, the prevailing attitude seems to be that most communication errors are either expected, someone else's fault, or weren't actually errors at all. It's not a horribly surprising outcome, considering the system in most hospitals is not set up for effective or efficient transmission of information, there is little accountability for communication errors, and training in proper communication is practically non-existent. Heck, even training in the improper communication typical of inpatient hospital services is practically non-existent, being delivered "on the job" in bits and pieces, typically while a student or resident is already being given patient care responsibilities and having to figure out how to perform on the fly.

I knew communication was a big problem in medicine before I started medical school, one that contributed to sub-optimal patient comes. Nevertheless, being on the physician side of things has been disturbingly revealing. Communication errors are routine, pervasive, and we're nowhere close to fixing those issues. For the most part, I'm not even sure we're trying to fix them.

Medical School Interviews

In Ontario, interview invites are just now starting to come out. Obviously an exciting time for applicants and I wish everyone reading the best of luck if they're waiting to hear back about possible interviews!

It's the first year with the new MCAT in play, so for schools that put a decent amount of stock into the MCAT, this could be an interesting admissions cycle. The main question is how the CARS section will be evaluated with respect to the old VR. The previous MCAT supposedly had the same scale for all sections, but in practice the VR tended to have lower scores compared to the other sections, at least at the higher ends where medical schools place their cutoffs. A score of 13 in the Bio section was much more likely than a 13 on the VR. The new CARS section has supposedly fixed that discrepancy; a 130 should be as likely on the CARS as on the science sections. That's a positive change in the long-term, but it means some short-term chaos as applicants try to figure out exactly where they stand.

It's also my first opportunity to be involved in the application process. My school allows 3rd year students to be interviewers, though they tend to take 4th year students if they can. I've only signed up at this point and don't know if I'll be needed, but I hope to participate. I consider the admissions process to be the most important step in medical education and the student who interviewed me 3 years ago couldn't have been nicer or more fair. It would be great to pay that service forward. As someone with an interest in improving medical education, I think it would be a great learning opportunity for me as well.

Anyway, another best wishes for those waiting to hear back, and a huge congratulations to those who obtain an interview. It's the first step of many on the way to becoming a physician, but it's a huge step, one that deserves acknowledgement. I'll keep my fingers crossed to get to know a few of you during the interview days!

Electives - Classmates Edition

We're rounding towards the half-way point of third year, which means it's crunch time for specialty choice. At my school, our first real "deadline" for setting us on our paths is on Friday, when some of our home-school elective choices are due.

While I've been wrapped up a bit in my own approach to electives and specialty choice, it's been interesting to hear from my classmates, who are all going through the same thing. There are a lot of different strategies to choosing electives, as well as a number of thought processes to picking a desired specialty. If history is any guide, most (though not all) of these strategies will work. It's a helpful reminder that there's no one "right" approach to electives.

I'm also just interested in seeing where all my classmates end up. There's a pretty wide variety of personalities in the class, plus wildly divergent interests, but it's still a guessing game as to where any particular person will ultimately fit. It's definitely true that people change their minds in clerkship - while some people have been consistent, many more have switched their goals, some dramatically so. Even as we settle into the home stretch of choosing specialties, there's still room for change, and I'm finding the rationale behind those changes quite intriguing. Really wish I had a crystal ball to see how it all ends up for my class!

Inefficient Education

If I could sum up my criticism of my medical education thus far, as well as what I've seen from others, it would be this - our current approach to teaching medical students and residents is unacceptably inefficient.

Pre-clerkship is too heavy on wrote memorization without sufficient context or repetition, which leads to a lot of forgotten information. Much of what is retained has minimal practical value. A lot of relearning becomes necessary later on.

Clinical rotations are often fragmented, with learners switching between rotations frequently. As a result, a lot of time and mental resources are spent figuring out what to do rather than how to do those tasks well. Repetition also gets lost, with higher emphasis on seeing the presentation of multiple diseases once, rather than multiple presentations of one disease.

I've written about this before, but continuity in instruction at all levels is sorely lacking. Aside from some smaller residency programs, learners have little opportunity to form meaningful, long-term connections with their instructors. Instructor-learner relationships are constantly be formed and broken, which takes up a lot of time and energy, while preventing deep insight into a learner's (or instructor's) areas in need of improvement.

Even with the move to pass/fail evaluations, current approaches place far too much emphasis on summative assessments instead of formative assessments. Learners then have to spend the bulk of their energies trying to perform instead of trying to learn, which in turn pushes more short-term memorization.

All these approaches are shown to reduce retention in learners, some quite substantially. To compensate for inefficient instruction, medical education usually turns up the intensity. Long hours per day, long days per week, long weeks per year, then long years of training. I've written plenty about my opinions on work hours (short version - they're too long) so I won't dwell on the subject, but I do wonder how much of the current stated emphasis for long training times is a self-fulfilling prophecy. That is, medical schools and residency programs argue long hours are necessary, then without any incentive to provide more efficient instruction, design curricula that require long hours.

The further I get into my medical education, the more I'm starting to see the many individual issues in medicine as interconnected concerns. It's also why I care a lot about medical education, because a good number of problems I see in medicine itself have roots in the way we educate physicians and other healthcare professionals. Likewise, problems in medicine often filter down into training. This inter-connectivity makes addressing concerns in medical education more challenging, as ripple effects into the broader healthcare system aren't necessarily appreciated and lead to resistance to change. However, it means that when positive change does occur in medical education, a beneficial ripple effect can also occur, resulting in improvements to the broader healthcare system.

In any case, regardless of the bigger picture, I think we can do more with less in medical education, if we're willing to break with some long-held traditions.

Hockey Post - World Cup Edition

Time for a quick hockey post on the upcoming World Cup - feel free to ignore the ramblings!

The World Cup is a bit of a money-grab, but it's international hockey, so I'll give it some interest. Team Canada has to name an initial 16-man roster, basically it's core players, before naming a full team. Here are my picks:

Goalie (2)
Carey Price, Braden Holtby

Price is the best goalie in the world, provided he's back to form when healthy. Holtby's been on a tear this year, but it's not a single-season performance - he's been solid for years now. I can't see them not naming two goalies in the first bit and while the other options (Luongo, Fleury) are fine, Holtby's performance has been slightly better, so he's earning an early spot.

Defensemen (5)
Duncan Keith, Drew Doughty, Shea Weber, PK Subban, Marc-Edouard Vlasic

Keith, Doughty, and Weber have plenty of international experience and are phenomenal all-around D-men, this year being no exception. PK Subban has been stellar for years and was under-appreciated in Sochi. He gets knocked for being a defensive liability, but it's an unfounded reputation these days - watch him play, look at traditional stats, or advanced stats, Subban's one of the best two-way defensemen in the league. His main weakness is undisciplined penalties, but he'll be on a tight leash on Team Canada and his upside it too great to pass up. At worst he becomes the 7th D-man. Vlasic's a role-player, to be used more in a shutdown role, but few players do it better and he's not a burden to the offense. There are some more talented players, some of whom I expect to make Team Canada, but in a short tournament reliability is key and no one's more consistent than Vlasic.

Forwards (9)
Jamie Benn, Tyler Seguin, Patrice Bergeron, Jonathan Toews, Jeff Carter, Corey Perry, Taylor Hall, Patrick Sharp, Brendan Gallagher

Benn and Seguin are self-explanatory. Right now they're the best two players in the NHL short of Patrick Kane and their underlying numbers are incredible. They can keep this pace up and they play so well together. Bergeron is such a unique player that he's worth it for the intangibles alone, but his offense (which was already very good) has hit a new level this year. Toews and Carter aren't having the best years, but they're defensively responsible with acceptable offensive contributions and strong international experience, so I give them the benefit of the doubt for a less-than-stellar season thus far. Perry's actually having a bad year, but luck's a big factor there - both he and Getzlaf are playing quite well on both ends, but aren't finding the back of the neck at the rate they normally do. Canada also lacks right wingers, so Perry kind of wins by default.

Hall was fringe candidate at the beginning of the year but he's putting together a strong season and has earned a spot. He'd be great in an offensively-oriented role. Sharp I would never have put on this list a few months ago, but he currently sits 5th highest scoring Canadian forwards (Benn, Seguin, Hall, and Bergeron are 1st through 4th). Sharp's mostly benefiting from riding shotgun with Benn and Seguin, but who cares? They'll be there anyway. Plus if those two need a different winger, he's got plenty of experience in a more defensive role with Toews. Gallagher is being mentioned more and more often by hockey pundits and I throw him on my short list with confidence. His advanced stats are amazing and he manages to be a pest without being undisciplined. He can single-handedly break a game open and everyone seems to get better playing with him. Like Perry, Gallagher's status as a right winger helps, as the competition for those spots is less (and may end up being filled by centers being shifted to the wing).

Obviously I've left some controversial omissions. No Crosby, no Stamkos, no Tavares, no Getzlaf. None are having great seasons. Getzlaf, like Perry, can blame bad luck - he's still decent on defense, so if the puck starts bouncing his way (as it should), he could easily earn a spot on the full roster. None of the others have the luxury of blaming chance, however. Crosby, Stamkos and Tavares have mediocre advanced stats to go along with their mediocre regular stats. These three are offensively-oriented centers who aren't generating that much offense. Everyone else on the list is either producing better offense or has a much more complete game (or both). Even for point-producing players, there are better options this year not yet on the shortlist in the form of Hoffman, Duchene, MacKinnon, or O'Reilly. Crosby, Stamkos and Tavares are big names to leave off the Team Canada roster, but tournaments aren't won by names, they're won by play - and they're just not playing well enough so far this year.

Family Medicine

Clerkship is when most people pin down their specialty choice, and that looks to be the case for me as well. It's only 4 months into clerkship and my preferences have definitely changed. Moreover, I'm a lot more certain in my selection. There's still room for change, but I've pretty well stratified the specialties on my short list, and I've only got one major rotation that could change things, so I think I'm set.

Without much fanfare, my current plan is to aim for Family Medicine.

Ironically, the rotation I haven't done yet that might change my mind is Family Medicine. If I have a truly awful experience there it'd certainly alter my approach, but at this point I've had quite a bit of direct FM exposure and generally enjoyed it, so I don't see that happening. Even if I don't find my FM rotation as exhilarating as some other rotations, that probably won't change my plans, the rotation just has to be sufficiently pleasant.

My thought process here isn't all that unique, and I've been a bit hesitant to make this post at all, but I figure it's worth spelling out.

1) I like outpatient medicine

Through my rotations thus far, there's been a bit of a recurring theme: I love my time in outpatient clinics (I'll throw ER in there as well), but get completely worn out by inpatient services. Basically if I can see a patient for a short period of time and send them on their way, I'm pretty happy. These services tend to have a bit more face-to-face time with patients, which is a big plus for me.

Inpatient medicine I find tends to get bogged down in bureaucracy and problematic miscommunications are routine. Too many providers with too little coordination between them. There's a reason being in hospital is a major risk factor for death and while it's a problem I would love to tackle at some point in my career, it's not an environment I particularly want to practice in for an extending period of time. Maybe community hospitals, with fewer services to manage, do a better job of this, but that brings me to my next point...

2) I want a residency that reflects my outpatient preference

There are a number of specialties that allow for a primarily-outpatient practice, not just family medicine. The problem is that most of them require a rather inpatient-heavy residency, especially in the first few years. I don't think I would enjoy years of an inpatient-dominated residency. Residency may be a short time compared to a whole career, but 5 years isn't exactly nothing. I'm coming up on my 5 year anniversary with my SO and it feels like a lifetime - a very happy one - since I met them. Add on the inevitable fellowship(s) required in many fields and the time difference between FM and Royal College specialties becomes pretty substantial. I don't want to spend that amount of time being miserable. FM doesn't avoid all inpatient work, but it does limit it to about 9 months or so maximum, mostly in the first year.

3) I'm eager to practice

To put things bluntly, a short residency is very attractive. I've mentioned before that I have some life goals to accomplish over the next 10 years or so, the biggest and most time-sensitive one being kids. A shorter residency means maybe having them after residency or at least getting to a point of professional and financial independence early in their lives.

I'm also getting a little tired of being a learner. Not tired of learning, of course, just tired of having that learning be subject to a bunch of extra requirements that come with being a learner - directed (rather than independent) learning goals, the endless evaluations, rapidly shifting from topic to topic... I'd like to be more able to tailor my education to my needs, rather than what others have determined I need to study. That won't likely happen until I'm out in practice.

4) I want a job

Few specialties have great job prospects and none are as flexible as Family Medicine. It's one thing to put in extra time to be a specialist, it's another matter entirely to do so without a desirable job at the end of it. There are one or two specialties that might be worth the extra training time, but not if I can't get a job I'm happy with at the end. FM pretty much comes with a guarantee of reasonable employment and for the foreseeable future, also a guarantee of location preference.

5) Trading ambition for stress reduction

The main thrust of my thought process leading to Family Medicine is stress reduction. Outpatient medicine is less stressful to me, for a variety of reasons. A residency that's shorter and outpatient-focused is similarly less stressful. Knowing I'd have a job at the end is a huge stress reducer.

In many ways, simply making the choice to pursue FM has been in keeping with the goal of stress reduction. FM doesn't require amazing LORs, heavy research experience, or specific electives to have a successful match. I've been able to focus on clerkship rotations more than filling out my CV, my elective choices have reflected my preferences rather than those of program directors, and I'll have many more options for where to do my residency. I wanted to take back some control over my education and my life - simply making the choice to pursue Family not only helps that goal in the future, it had an impact right now. I really can't express how much a difference that sense of control has made to my own well-being.

High Unemployment, Long Hours

The current job market for physicians is a bit weird right now. There are several specialties with a combination of high unemployment/underemployment (by physician standards), but long work hours for those employed and generally high pay. Many surgical specialties fall into this category. I've expressed that this is a rather absurd situation, as physicians who likely need shorter hours and have the per-hour income to afford an associated decrease in take-home pay from working less have plenty of people to pick up additional work yet who aren't being utilized.

I haven't had a good reason for why this isn't happening, so I've assumed that physician stubbornness (or perhaps greed) in these specialties is to blame.

I stumbled across a random comment that may provide a better explanation, essentially boiling the situation down to bargaining power. Hospitals and universities in Canada would generally prefer to hire the minimum number of specialists necessary to get the work they have done. In specialties with more physicians than positions, the hospital (or physician group) has additional leverage to insist on longer hours - after all, if one physician doesn't want to handle a standard load, there are plenty of other physicians who would gladly do the work.

Similarly, in specialties where the number of positions vastly exceeds the number of available physicians, it's the doctors who have the bargaining power. The is a major need for more psychiatrists, yet they tend to work relatively short hours. Same for Emergency Medicine, which has reformed itself to have comparatively light schedules, albeit with shifts at all times of the day, and has a very favourable job market.

Granted this doesn't explain everything - Radiation Oncology has low average work hours, decent compensation and a terrible job market. Patient population, culture within the specialty, and funding models obviously have an impact on the work hour and employment situations. Nevertheless, it's an interesting theory that I thought I'd share, one I intend to keep in mind as the job market in certain medical specialties evolves.

Burnout Culture

Really wanted to highlight a post via KevinMD of a burnt-out surgeon. First, I think it gives a good description of how medicine leads to burnout, namely that it's a long process. Individual  moments certainly stand out and can precipitate reactions like a breakdown or quitting, but a physician is set up to break long before any one event pushes them over the edge.

Second, stresses on a physician are multi-factorial. One of the commentators provides a nice framework to categorize the stresses:

1) Workload - too much work, long hours, not enough time for each task
2) Control - limited autonomy, limited schedule control
3) Reward - insufficient monetary, non-monetary, or personal compensation
4) Community - lack of sense of belonging, difficult coworkers or bosses, habitual conflict
5) Fairness - unequal treatment between physicians, or unjustified treatment of all physicians
6) Values - work that conflicts with your broader ideals

Every job has concerns related to some of these categories. What the burned-out surgeon's story makes clear is that many physicians are having stress in almost all these areas: long hours, too much work in those long hours, little schedule control, inadequate support from colleagues, the list goes on. Each physician will have their own mix of personal stresses, but it doesn't tend to be a single one that causes a physician to become burned out, it's the combination of stresses that does it.

Some stresses in medicine are going to be unavoidable. A regular, 40 hour work week for all physicians probably isn't viable without massively slashing overall compensation or having physicians provide horribly substandard care. Full schedule control is impossible in many specialties. Some conflicts between physicians are necessary, even productive.

Yet, there are a lot of stresses physicians face that could be minimized or eliminated. 40 hour weeks may not be feasible, but that doesn't make 60, 70, or 80 hour weeks necessary. Coverage for 24/7 services requires people working when they'd probably rather not and while night shifts are never good for a person's health, many workplaces figure out how to employ people at all hours of the day without causing the system-wide levels of stress seen in medicine. Open conflict between physicians is actually quite uncommon I've found, yet a degree of animosity towards other physicians and healthcare workers seems to run deep and it's completely unnecessary.

The author of the article is American, and the US healthcare system does have its differences relative to Canada, but the contributors to stress are very similar. The major salient difference may work in our favour - while in the US, physicians are often hospital or clinic employees, subject to the whims of their employers, Canadian physicians typically function as independent contractors of sorts, with more collective leeway to make positive changes to reduce our own stress. While our American colleagues are largely confined to railing against the system controlled by non-doctors, Canadian physicians just need to convince each other that this is a problem worth addressing.

However, as the piece laid out, fellow physicians can be the greatest obstacle in taking care of ourselves. Calls for help frequently go unanswered and resentment absolutely exists for those who work less in an effort to recover from or prevent symptoms of burnout.

I think we're getting there, all barriers aside, and while change has been frustratingly slow, it's at least moving in the right direction. Yet, as anecdotes like this make clear, there's good reason to pick up the pace.

Reading About Healthcare

I like to read. A lot. About all different things, but being in medical school, I like to keep up with what's going on in healthcare. Knowing that I get a lot of traffic from pre-meds and other medical students, I thought I'd share the resources I use to stay up-to-date on what's going on in healthcare outside of my local bubble.

Blogs

The Incidental Economist (link)

Focusing on healthcare policy, particularly from an economic perspective, TIE does a great job of contextualizing system-level concepts in medicine. Their posts are well-written and provide non-technical explanations for technical subjects. There is a fair bit of medicine in there too - most of the contributors are policy experts rather than physicians, but Aaron Carroll is a pediatrician who does a great job of using an evidenced-based approach to common medical or quasi-medical questions. He also makes very helpful short videos! It's a bit American-centric, so not every topic applies well to the Canadian healthcare system, but being concept-focused, even the American topics provide some useful means of understanding healthcare in Canada too. Overall, I find this site to be my highest-yield resource. Check it out if you've got a real interest in healthcare policy.

Healthy Debate (link)

Canadian content, which is great, and there are some articles with some really unique insights into the Canadian system. It doesn't have too many contributors however, and I find some of the articles to be a bit fluffy, so I don't check the site often. In typical Canadian fashion, it also tends to play things fairly safe, with many articles taking rather non-controversial or vague stands on issues. In some ways, it's more a news site than a blog or opinion site. Where Healthy Debate does shine is in the comments, which are generally high-quality and provide for reasonably insightful discussions. Posters are more willing to take hard stands - and to defend their viewpoints - which also gives a good look into prevailing opinions in Canada's healthcare system, including those of physicians. It's worth checking out every month or so.

KevinMD (link)

In many ways the grand-daddy of healthcare blogs, KevinMD is now mostly an aggregator of blog posts from other blogs, some better than others. It's an American site with a distinctly American focus, so a lot of what's on there has minimal value for Canadians. There's also a fair number of fluff pieces. Still, it updates so regularly that even if only one in four posts catch your interest, there's still plenty of content to go through. The comment section provides some interesting viewpoints from our American colleagues, but don't get too absorbed in them - unlike Healthy Debate, this is not a place for measured discussion. Opinions get thrown around with little or poor justification and seem permanently unresponsive to counter-points. It's also a rather commercial enterprise, with Kevin Pho, the site's founder, talking a lot about how physicians can increase their online presence. It's a great resource for bloggers if your primary goal is to be seen/heard by more people, but being a content-focused person, I find the emphasis on wide exposure rather than quality content a bit off-putting at times.

Evidence Network (link)

A University of Manitoba-based collaboration project between healthcare policy experts from a variety of backgrounds, the Evidence Network provides easy-to-understand position pieces and commentary on the Canadian healthcare system. It's not exactly a blog, so it doesn't seem to update too often, but the quality of the pieces is exceptional - as the name suggests, they really draw off the evidence in a comprehensive manner. Most of their positions are nothing I haven't heard before, but their circle of experts have expressed them in such a clear, concise, Canada-specific manner that they're worth a thorough read. Anyone looking for an introduction or refresher on Canadian healthcare policy, particularly from an economics perspective, could do a lot worse than reading the Evidence Network's articles.

Doctor Grumpy in the House (link)

Uses examples from Doctor Grumpy's practice to highlight the absurdities present in medicine. American practice, but the instances are generally quite applicable to Canada. Always hilarious, usually not too serious. Good for a laugh every now and then for stress relief.

Forums

Premed101 (link)

Needs no introduction - if you're on my blog, you probably got here from Premed101. Good resource for Canadians looking to navigate getting into medical school or residency, arguably the only free, reliable, online resource for some important questions. Canadian-focused, so a bit of a smaller community which goes through periods of relative inactivity. Also a bit dominated by a small group of posters - which I'll fully admit includes me - so what gets posted isn't exactly representative of the broader community in undergrad, medical school, or residency, but I do find there's at least a range of opinion and room for different ideas. I've had some excellent discussions on Premed101, which is why I generally keep coming back to it.

Student Doctor Network (link)

The American Premed101 (ok, it's probably the other way around), it's a great resource if you're looking at doing anything in the US. Bigger community, so it's a decent place to get a variety of perspectives on medicine. Chock-full of useful or funny anecdotes if you search around enough. Not the greatest forum for discussion - threads seem to get pretty non-constructive fairly quickly - but still good for simple data-gathering about viewpoints about medicine, particularly from an American perspective.

News Sites

Medicine is a social occupation. Healthcare is very much society-dependent, and society is changing all the time. I find it very useful to keep up with the world outside of medicine, or at least to see what non-medical people read about healthcare. I meander between different news organizations when trying to get general information about the state of the world, including the CBC, the Globe and Mail, Maclean's, the Guardian, CNN, the New York Times, the Washington Post... it's changed a lot. My go-to at the moment is...

Vox (link)

Started by a bunch of younger, established, left-leaning journalists a few years ago, Vox is an online-only news organization. It tends to go a bit beyond reporting the immediate story of current events, instead trying to inject some fact-checking, context, or counter-points to common media narratives. This raises the level of reporting substantially and avoids some common journalistic pitfalls. The problem with trying to inject context into news, however, is a higher potential for bias. It's a left-leaning site (for an American organization at least) and sometimes misses or ignores contextualizing information that goes against established viewpoints of their main staff. These tend not to be egregious errors and because their articles actually make concrete conclusions, they're pretty transparent about their viewpoints, so at least it's easy to clue into where their bias lies. It's not a uniquely good news site, but I'd say it's a cut above most.

Raw Data Sources

Canada has a large number of organizations that collect information on the state of healthcare, so no one site is going to have all the necessary information. Government departments (local, provincial, and federal), physician organizations (CMA, OMA), and accrediting bodies (CFPC, RCPSC) all have good data. Here are the sites I visit most often for raw data.

CaRMS (link)

Everyone involved in Canadian medical education knows about CaRMS. It's the organization that handles our residency matching process, the most important post-medical school admissions event, so it's kind of a big deal. It's also a fantastic source of data on the Canadian medical education system. They've got reports on residency matches stretching back decades, as well as program information for the current match cycle. I pull a lot of raw data from them when looking at the medical education pipeline.

CIHI (link) 

The Canadian Institute for Health Information is not a site I visit often, but if you're looking for an obscure data point on healthcare in Canada, if you find it anywhere, chances are you'll find it there.

Health Force Ontario (link)

The most comprehensive job posting sites for physicians. Far from complete - a good number of positions for doctors aren't posted anywhere - but it's a large and searchable database, which puts it a good cut above anything else I've found. I like it for the purposes of contextualizing future career opportunities. Finding even one job that is appealing in a specialty is a great motivator to go into it, to see what's at the end of the tunnel. Many other provinces have similar sites (British Columbia's is notably excellent).

You Should Study Something You Enjoy

One of the more controversial topics for undergrads considering medical school is what program to go into out of high school. A common refrain is that you should take something that interests you. The other school of thought is to go into programs known for easy courses and/or high averages, nevermind personal interests.

For optimal chances of a medical school admissions, the latter approach is probably better. I'll even tell you the best programs to go to - McMaster Health Sciences and Western Medical Sciences. They have good success rates for getting into medical school, well beyond that of most programs. I have two degrees and the number of people from these programs with GPAs higher than the top person in either of my programs is astounding. If your only desire in the world is to get into medical school, go to one of these programs.

However, I fall decidedly into the "follow your interests" camp. Here's the thing, most people who come out of high school wanting to get into medical school won't end up as physicians. Some will get turned off of medicine entirely, some will discover more compelling career paths, and some just won't get in despite their best efforts. This is true even for people who take the "optimal" route to medicine.

The danger in going into a program you don't have a ton of interest in, besides spending four years of your life studying something you don't like, is that the consequences for not successfully matriculating to medical school are significantly higher and failure remains a distinct possibility. Some people say to do what you like because you'll be better at it and there's some truth to that, but you can be good at fields that aren't your first choice to study. No, the big problem is that if you don't like your field and you don't get into medical school (and don't enter another professional school), your options are very limited outside your field of study. That means sticking with something you're not super passionate about by finding employment or graduate work, or trying to make a big shift in your career trajectory.

The benefit of going into something you enjoy, even if you don't achieve your ultimate goal of medical school (or if you choose a different goal in life), is that you've got a good base to build off of and lots of palatable career options available. The obvious other advantage is that hopefully you'll enjoy your studies, making it easier to put in the extra effort needed to get the necessary GPA for medicine and leaving more time for things like MCAT studies and ECs. There's also the more nebulous benefit of prioritizing happiness, even early in your career. While it's admirable to sacrifice for future gains, people can get stuck in the habit of sacrifice, always putting off rewards for a
happy future that never quite comes. Working hard and forgoing easy pleasures isn't the same as being miserable. 4 years of undergrad is a long time, about 5% of a typical life, you should enjoy that time!

There's nothing wrong with a bit of compromise when choosing an undergrad. Some programs are brutal when it comes to marks - even a highly intelligent, motivated person is unlikely to get the grades needed for medical school, especially since most medical schools don't consider program difficulty. It may be worth avoiding those programs if you have an interest in medicine, instead choosing a program that still holds your interest, but has a higher likelihood of getting competitive marks. Likewise, if there's a program that is known to put lots of people into med school that seems like it would be a good fit even if you didn't go into medicine, that could be a good option, even if another program seems like it might be a marginally better fit.

Still, undergrad students should like what they study, with ease of marks being a secondary consideration.